Provider Demographics
NPI:1588691273
Name:MIKULA, BRIAN PATRICK (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:PATRICK
Last Name:MIKULA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4056 PLAINFIELD AVE NE
Mailing Address - Street 2:STE. E
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1630
Mailing Address - Country:US
Mailing Address - Phone:616-365-0255
Mailing Address - Fax:616-365-0975
Practice Address - Street 1:4056 PLAINFIELD AVE NE
Practice Address - Street 2:STE. E
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1630
Practice Address - Country:US
Practice Address - Phone:616-365-0255
Practice Address - Fax:616-365-0975
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4443376Medicaid
MI4443376Medicaid
MI0M21360Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER